This particular guide draws heavily upon the shared lessons of experienced advocates in both developed and developing countries. It is primarily based on the collaborative work of advocates convened by the American Cancer Society, the Polish Health Promotion Foundation and the Open Society Institute, in collaboration with the International Union Against Cancer, in Warsaw, Poland during the spring of 2002.

Each guide is designed to provide answers to five simple but effective strategic questions, which vary slightly depending on the objective:

1. What do we want? (The objective)
2. Who can give it to us? (Those whom we need to convince; the target audience)
3. What do they need to hear? (Effective messages)
4. Whom do they need to hear it from? (The most effective messengers)
5. How do we get them to hear it? (Creative strategies for getting their attention)

Closing The Gap Strategic Guide #1:

In most countries, doctors and other health professionals are highly respected and influential health and community leaders. According to David Simpson, Director International Agency on Tobacco and Health, doctors probably have "the greatest potential of any group in society to promote a reduction in tobacco use, and thus, in due course, a reduction in tobacco induced mortality and morbidity." They have the unique potential to contribute to tobacco control in complementary ways:

• As role models in not smoking, or quitting smoking;
• In counseling patients not to smoke;
• In providing smoking cessation treatment to patients; and
• In organizing and speaking out publicly and lobbying for comprehensive public policies to control tobacco use.

But there are too many doctors in too many countries that do not consider any aspect of tobacco control to be part of their professional responsibilities other than to treat illnesses caused by tobacco use. This has proved particularly harmful in developing countries that lack strong advocates for tobacco control – often the very same countries in which doctors are most respected and influential.

In developing countries, doctors also serve as parliamentarians, who are highly influential on matters of medical science, such as tobacco control. However, they rarely choose to speak out against tobacco because they do not see themselves as natural leaders for public health advocacy.

In countries with the highest smoking rates, doctors’ smoking rates are sometimes higher than those among the general public. There, doctors serve as negative role models.

Even the first steps – getting doctors to quit smoking – can have profound public health benefits. A doctor who has successfully quit using tobacco is far more likely to become an advocate for tobacco control than one who is still smoking (and is in denial about the personal risks of smoking, as well as of his or her influence on the smoking habits of others).

Dr. Thomas Glynn, Director of Cancer Science and Trends at the American Cancer Society observes:

Our messages must be presented in such a way that doctors themselves will realize that their professional obligations require greater engagement in tobacco control. This would include especially those doctors whose patients – and potential patients – are at the greatest risk of tobacco-caused disease and mortality (e.g., oncologists, cardiologists, and pulmonary physicians). It would also include physicians with family-oriented practices, (e.g., pediatricians, family physicians and internists), which make them more open to the message of tobacco's risks for family members.

Female medical students and doctors should be one of our primary targets. In Poland, for example, there has been a dramatic decline in smoking among women doctors – far below smoking rates for male doctors; and those who have quit are more likely to become engaged in both cessation counseling and advocacy.

Our target audience should also include those who have the most professional influence with doctors, including deans of medical schools, professors of medicine, and Nobel- and other respected prize-winning doctors and medical scientists.

It also encompasses those who have institutional and economic influence with doctors. This would include health ministers and senior public health officials, hospital administrators, Boards of Directors, hospital medical department heads, nursing directors, as well as inspectors of hospital hygiene and safety.

Even in developing countries, many doctors are relatively well informed of the health risks of smoking. The primary impediment to their accepting responsibility for tobacco control lies in their failure to recognize that their professional responsibility extends beyond the treatment and cure of tobacco-caused disease and includes the prevention and cessation of tobacco use. This lack of recognition is reinforced by medical compensation systems that rarely pay for counseling or cessation services.

According to the World Health Organization (WHO):

According to the American Medical Association:

According to the American Academy of Family Physicians:

• Avoid smoking and the use of tobacco products in their personal lives;
• Assess and document smoking and tobacco use status as part of the medical history for every patient; and
• Provide cessation counseling and other proven therapy to all patients who use tobacco."

According to Health Professionals Against Smoking:

According to the European Medical Association on Smoking or Health (EMASH):

Here are examples of some other messages on quitting and providing cessation counseling that might be effective when tailored for particular target audience:

• A psychiatrist who smokes while treating an addicted patient is no different from a psychiatrist who takes cocaine under the same circumstances.
• A cardiologist who fails to provide cessation counseling to a patient who smokes is no better than a cardiologist who neglects to prescribe a cholesterol-lowering drug.
• In developed countries today, a cardiologist who sees a patient with high blood pressure would never fail to take that patients smoking history.

• "In smoking cessation, the decisive value is assigned to the physicians approach and his/her assistance. A mere advice from the physician not to smoke, increases the likelihood of successful quit rate in the patient by about 10 percent."

From the American Academy of Pediatrics:

"Pediatricians play a crucial role in reducing both tobacco use (by children, adolescents, and their parents) and exposure to tobacco smoke and should rank this among their highest health prevention priorities.

Doctors also need to hear that their interventions can have a powerful impact, not only in cessation counseling and treatment, but in policy advocacy as well. David Simpson says "such messages are empowering – there is something they can do to alleviate the suffering from tobacco caused disease."

For example:

• Polls show that doctors remain among the most respected and trusted community voices on matters related to health, including public health policies.
• An oncologist may save more lives by lobbying for tobacco control laws for several hours than treating lung cancer patients for a lifetime.
• A letter by a citizen to the editor of a city newspaper demanding that the city authorities take action to enforce local clean-indoor non-smoking rules may well be ignored, but such a letter from one or more doctors will almost always be printed. It is hard for tobacco industry lobbyists and the politicians who do their dirty work to discredit the concerns of a physician who takes time from his or her busy schedule to protect the lives of children from exposure to tobacco, or advertising that glamorizes smoking.

There is also a need for "narrowcast" messages –those designed for a particular, but important, audience.

• For heads of medical societies: In developed countries, medical (e.g., oncology and cardiology) societies have been in the forefront of the most successful tobacco control initiatives.
• For the deans of medical colleges: Medical colleges with a serious commitment to the prevention, as well as the treatment, of disease cannot ignore the importance of training in tobacco use prevention and cessation. Such interventions have a greater potential for sparing lives and improving health than many medical and surgical courses combined!
• For hospital administrators: The continued presence of smoking doctors in your facility is one certain sign – to patients and the public – of the backwardness of your institution.

As Krzysztof Przewozniak of the Polish Health Promotion Foundation says, "Doctors believe doctors." Doctors who have already become tobacco control advocates are perhaps the most powerful messengers to other doctors. This is especially true of those doctor-advocates who have institutional and economic influence on other doctors and/or hospital administrators. While they are not great in numbers, many health ministries and tobacco control non-governmental organizations (NGOs) include at least a few leading doctors who are influential with their medical peers.

Medical school professors and their curricula offer a prime opportunity to educate young doctors about the hazards of tobacco use. It is also an excellent chance to introduce them to the possibilities of engaging in tobacco control activities as members of the medical profession. In some schools, medical students adopt a local high school and spend their years of training working with a specific group of students to influence their health habits. This experience helps them to understand the difficulties in changing social norms, but also helps to realize the importance of public health interventions like tobacco cessation and prevention.

Physicians want to practice good medical standards. By making tobacco cessation and prevention integral parts of local standards of modern care, physicians will follow their local peers to eliminate smoking in clinics and hospitals; identify patients who use tobacco products and track efforts to get them to quit; and help medical staff to understand the importance of public policy in national efforts to reduce premature death and disease caused by tobacco use.

In some countries, leading physicians have access to the mass media – often in the capacity as guest experts on news programs and talk shows, and sometimes with their own regularly scheduled health guidance programs. Such access to the media may give them the opportunity to "narrowcast" their messages to their colleagues about the importance of getting involved in tobacco control.

One physician advocate, Dr. Elmer Huerta, originally from Peru, hosts a radio show to discuss health issues in Spanish in the United States. This led to a cable television show for him, and he is now a celebrity in the U.S. Latino community, known especially for his tobacco control advocacy.

Patients themselves – and especially organized patient organizations – can take the initiative to influence doctors' behaviors.

Other effective messengers include senior health ministry physicians, WHO regional advisers medical ethicists, leaders of medical and specialist societies, and medical writers in mass media publications.

Medical societies. Medical societies are in a unique position to influence the behavior of their members. They can:

• Conduct surveys of their members, which would include questions about their smoking patterns, the extent to which they provide tobacco use counseling and cessation treatment, and their willingness to become engaged in tobacco control advocacy;
• Organize plenary speakers and panel discussions at society conferences and workshops;
• Adopt resolutions and issue ethical opinions on member responsibilities in tobacco control;
• Publish stories in their journals and newsletters about directives, ethical opinions, and other related materials issued by their international affiliates, as well as model tobacco control initiatives taken by member societies;
• Advocate for health care system reimbursement for cessation counseling and treatment; and
• Issue press releases, hold press conferences, make members readily available for news and talk show appearances, and organize direct lobbying of parliament by medical society leaders.

David Simpson writes:

The Tobacco Advisory Group of the Royal College of Physicians of London published a report in February 2000, entitled Nicotine Addiction in Britain. By emphasizing the "central role of nicotine addiction in smoking: its physical, pharmacological and psychological effects," this report encouraged physicians to make smoking a "major health priority in Britain." It also made specific recommendations "for the ways in which smoking could be managed by doctors and health professionals in the future."

Since 1993, the Finnish Medical Association has promoted awareness and action among its members by:

• Placing regular articles in the Association's journal on the risks of smoking;
• Doctors Against Tobacco – a campaign to persuade doctors and health care professionals not to smoke;
• A campaign to prevent hospitals selling tobacco and promoting a smoke-free environment;
• A campaign aimed at the general public;
• Providing information for medical students about the risks of smoking;
• Providing information for schools; and
• Lobbying for legislation to prevent smoking in public places.

The tobacco control activities of the Slovak Medical Association have included:

• Lobbying for the implementation of a comprehensive tobacco control law;
• Instigating a national plan of tobacco control activities;
• Holding meetings to lobby workplaces to safeguard health;
• Encouraging "Quit and Win" competitions; and
• Promoting smoking cessation through sponsorship, educational programs, school health lessons and epidemiological research.

Dr. George Kotarov, with the Bulgarian National Center of Public Health and a member of the Bulgarian Psychiatric Association, challenged his fellow society members to treat tobacco use as seriously as other addictions, and cited nicotine addiction treatment codes in support of his arguments.

In September 2001, Dr. Istvan Mikola, the Hungarian health minister at the time, made a heavily publicized declaration in which he called for a smoke-free health ministry. His main argument was that health officials, especially those working in the Ministry, should set a good example for the people of the country by not smoking in the workplace or not smoking at all.

President of the Czech Medical Association (CMA) Professor Jaroslav Blahos, who also served as President of the World Medical Association, took a strong leadership position in dedicating the CMA to tobacco control. Under his leadership, the CMA organized a Working Group on Tobacco Dependence. Also, twice a year, a two-day, post-graduate course is held on the treatment of tobacco dependence. Since 1993, 60 smoking cessation clinics have been held in cities and towns throughout the Czech Republic.

The CMA distributes twelve leading medical journals. Each time new guidelines for smoking control are promulgated by the WHO or other international or national organizations, they are immediately published, in the Czech language, in the journals.

The Use of Humor. Doctors, like many others, do not always react well to messages that are lectured to them. An alternative approach to delivering messages can be through the use of provocative, but culturally sensitive, humor. Even if these messages provoke controversy, there is the potential to catch the attention of doctors and educate them as a result.

If you cannot otherwise get the attention of medical society leaders, consider introducing a satirical resolution at an oncology society conference to provoke lively debate. It might go something like this:

1. To encourage society members who now smoke to continue smoking (especially in the presence of patients) so as to reinforce the smoking addiction of patients and others who look to doctors as role models;
2. To instruct society members that they may not, under any circumstances, offer counseling or cessation treatment to patients who smoke; thus, ensuring that the supply of lung cancer patients continues to expand; and
3. That members of the Society must vigorously lobby against bans on cigarette advertising, increases in cigarette taxes, clean indoor air laws, or any other public laws and policies that threaten the future supply of oncology patients.

Medical Schools. Medical schools have a critical opportunity to educate and motivate emerging doctors when they are in their formative stage. There are several complementary approaches that can be taken by medical school deans and professors:

• Courses in tobacco control treatment can be offered and even mandated within the curriculum;
• Tobacco control responsibility can be incorporated into orientation lectures and brochures for incoming students;
• Medical school students can be recruited for diverse tobacco control projects, from working in cessation clinics, to conducting surveys of tobacco use by doctors in medical facilities.
• Professors can use their status to speak out about the importance of tobacco control, not only in classes, but also in medical forums, to the media, and to parliamentarians (including physician-parliamentarians).

Medical schools may also wish to organize peer educator groups, which would get students involved in anti-smoking work well before concluding their studies.

Dr. Eva Kralikova in the Czech Republic has been a pioneer and model in advocating for and implementing medical school activism in tobacco control. Now, every student in each of the seven faculties of medicine in the country must take a course in tobacco control. At her faculty, Dr. Kralikova has been able to assign teams of students who, when they return to their respective home cities for vacation, approach local health clinics to survey medical staff on their smoking behavior.

This action provides:

• Surveys of prevalence among doctors;
• Heightened awareness among health care staff of tobacco control – and, perhaps, of their potential exposure to criticism for failure to address smoking among clinic doctors and staff; and
• Heightened awareness and engagement by medical students in tobacco control.

Based on a recommendation by Sir John Crofton, published in the International Union Against Tuberculosis and Lung Disease (IUATLD) bulletin, and the British Medical Association model, Dr. Kralikova successfully argued that each medical faculty should have at least one member on its staff who would be responsible for ensuring that students received tobacco control education. Since 1994, each medical student has completed at least two hours of instruction on the treatment of tobacco addiction. Tobacco education coordinators from each medical faculty also meet once a year to share their experiences in teaching treatment, and to share survey results on smoking prevalence among doctors and nurses.

Dr. Kralikova has found other ways to stimulate student involvement, such as organizing student conferences on tobacco control. The best student presentation is awarded with a prize, which consists of a scholarship to take part in the Society for Research on Nicotine and Tobacco conference in Spain 2002.

In April 2002, Health 21 Hungarian Foundation organized an essay writing contest on various smoking related topics for students of the S. Medical School and a Budapest-based nursing school. This contest served as yet another way to motivate young medical professionals to consider smoking and health issues.

Health Ministries. There are many ways, both direct and indirect, that Health Ministries can enlighten, encourage, and even shame doctors into taking more responsibility, both for their own smoking habits and in tobacco control efforts. Ministries can:

• Initiate surveys of smoking habits among doctors and other health care providers;
• Advocate, or provide funding, for cessation treatment reimbursement within the health care system;
• Advocate for national tobacco control legislation (as in Poland) that provides grants to doctors who organize programs to recruit and train doctors in smoking cessation treatment;
• Circulate pronouncements about the roles of doctors in tobacco use prevention and control amongst its members that are from WHO or other authorities; and
• Organize a network of smoke-free hospitals, including smoke-free doctors.

Voluntary Health NGO’s. NGO associations (such as the American Cancer Society, America Heart Association, and American Lung Association) have played, and can continue to play, a strong role in recruiting doctors to tobacco control. They can:

• Develop and maintain a list of doctors who are active in tobacco control, who will recruit other doctors, lecture at medical forums, and speak with the media about the need for doctors to be engaged;
• Issue brochures and guidelines in local languages calling upon doctors to become fully engaged in tobacco control;
• Petition medical societies to encourage their members to become more involved;
• Hold workshops for doctors;
• Offer resolutions at national, regional, and international tobacco control and other conferences that call upon doctors to become more fully engaged;
• Help organize talk show debates about doctors’ responsibilities;
• Encourage medical leaders to write letters and opinion articles to newspapers;
• Endorse scientific articles on the effectiveness of doctor interventions;
• Provide the mass media with profiles of doctors who save lives through counseling and advocacy;
• Promote newspaper editorials about the connection between medical ethics and the tobacco control responsibilities of doctors;
• Publicly recognize local physicians who take time to reduce tobacco use by implementing programs to reduce tobacco use, promote public policies to reduce exposure to environmental tobacco smoke, etc.; and
• Organize media events featuring visiting public health leaders, such as WHO spokespersons.

The potential for constructive collaboration between tobacco control NGO’s and medical societies is illustrated by the alliance between Dr. Cornel Radu-Loghin, leader of Romania’s tobacco control advocacy organization Aer Pur, and Dr. Florin Mihaltan, a pneumologist and epidemiologist in Romania. The two doctors met at the 1997 World Conference on Tobacco OR Health in Beijing, China.

Upon his return to Romania, Dr. Mihaltan joined Dr. Radu-Loghin in Aer Pur, and began recruiting his fellow pneumologists to tobacco control advocacy. At the same time, Dr. Mihaltan started a medical school course on smoking cessation and advocacy. Together they organized a cessation-training workshop for twenty-five Romanian doctors last December, most of whom were members of the Romanian Society of Pneumology. Their next plan is to extend this program to family doctors.

Kryzszstof Przewozniak of the Polish Health Promotion Foundation collaborated with pharmaceutical and health insurance companies, and now offers training to doctors on the treatment of tobacco dependence. He explained that pharmaceutical companies and health insurers have a unique influence on doctors, and pointed out that the doctors were more interested in participating in the conferences when the invitation had only come from the Polish Health Promotion Foundation.

As in all forms of advocacy, creativity is both essential and welcome. An example can be found in the Romanian team that developed an award-winning plan for their "Great National Smoke-Out." The program included a poster-contest by school children on the hazards of tobacco use. By recruiting doctors to act as judges for the contest, they not only involved the children in tobacco control, but the doctors as well.

Appendix – Worksheet

This worksheet was created by the Fellows of a Program that the American Cancer Society conducted in Mumbai, India, and is included to illustrate the practical, concrete steps that tobacco control coalitions and NGO’s can take to meet this challenge:

The American Cancer Society would like to express its deep appreciation to the participants in the Warsaw 2002 Tobacco Control Fellows Program for many of the insights and lessons included in this guide, as well as to the international tobacco control experts whose voluntary reviews greatly enriched each draft.

The Society is particularly grateful to Michael Pertschuk, Karen Lewis, Jessica Lazar, Laura Wyshynski, Theresa Gardella, and other staff members of the Society, the Advocacy Institute and the National Center for Tobacco Free Kids for their help in research, writing, editing, designing, and publishing this guide!

Deepest of thanks are also extended to tobacco control colleagues from around the world who took the time to review initial drafts of this guide: Dr. Tom Glynn, Dr. Eva Kralikova, Dr. Bob Jaffe, John Pinney, Dr. Steven Schroeder, David Simpson, Dr. Tibor Szilagyi, and Myra Wisotzky.

Ms. Theresa Gardella, Manager, Tobacco Control Project, Advocacy Institute, Washington, DC

Mr. Ruben Israel, UICC Globalink, Geneva, Switzerland

Dr. Vesna Kerstin-Petric, M.Sc., Ministry of Health, WHO Liaison Office, Ljubljana, Slovenia

Dr. George Kotarov, Chief Specialist, National Center for Public Health, Sofia, Bulgaria

Dr. Eva Kralikova, Institute of Hygiene and Epidemiology, Smoking Cessation Clinic, Charles University, Prague, Czech Republic

Mr. Mike Pertschuk, Co-Director, Advocacy Institute, Washington, DC

Mr. Krzysztof Przewozniak, Research Director, Health Promotion Foundation, Warsaw, Poland

Mr. David Simpson, IATH, London, United Kingdom

Dr. Cornel Radu-Loghin, President, "Aer Pur" Romania, Bucharest, Romania

Dr. Luminita Sanda, Counsellor, General Directorate of Public Health Ministry of Health and Family, Bucharest, Romania

Dr. Blazej Slaby, Ph.D., Head, "Stop Smoking" (NGO), Bratislava, Slovakia

Ms. Myra Wisotzky, MSPH, Program Consultant, Office on Smoking and Health, Program Service Branch Centers for Disease Control and Prevention, Atlanta, GA

Prof. Witold Zatonski, President, Health Promotion Foundation, Warsaw, Poland

Dr. Prakash Gupta, Tata Institute for Fundamental Research, Mumbai

Dr. Surendra Shastri, Tata Memorial Hospital, Mumbai

Ms. Mira Aghi, U.N. Consultant, New Delhi

Ms. Shoba John, PATH Canada - tobacco control program coordinator, Mumbai

Ms. Alka Kapadia, Cancer Patients Association, Mumbai

Mr. Bobby Ramakant, Key Correspondent, Health & Development Networks; Coordinator INGCAT (Task force for South East Asia), Lucknow

Mrs. Monika Arora, All India Institute of Medical Sciences, New Delhi

Dr. Dhirendra Sinha, School of Preventive Oncology, Patna

Prof. Madubhai Shah, Consumer Rights Lawyer, Ahmadebad

Mr. Taposh Roy, Voluntary Health Association of India, New Delhi

 Appendix: Resource Materials

 The American Academy of Family Physicians: http://www.aafp.org/policy/xl879.xml

The American Academy of Pediatrics, Committee on Substance Abuse 2000-2001; Policy Statement

Pediatrics, Vol. 107, Num. 4, April 2001, pgs. 794-798

Obtained online at: http://www.aap.org/policy/re0041.html

The American Medical Association: http://www.ama-assn.org

European Medical Association on Smoking or Health (EMASH): http://emash.globalink.org

Health Professionals Against Smoking: http://www.ieo.it/inglese/smoking.htm

The World Health Organization: http://www.who.int/archives/tohalert/4-96/e/ta6.htm

The WHO's Tobacco-Free Initiative: http://www5.who.int/tobacco/page.cfm?tld=71#ImplementingTreatment

Information about the Finnish and Slovak Medical Associations obtained at:

http://www.tobacco-control.org/tcrc_Web_Site/Pages_tcrc/Resources/tcrc_Research.htm

Baska, T., Madar, R., Straka, S., Kavocova, E. "Pharmacotherapy in Smoking Cessation", Bratisl Lek Listy 2001; 102 (6): 298.301. Obtained online at: http://www.elis.sk/bll/01/full/bll0601g.pdf

Simpson, David. Doctors and Tobacco: Medicine's Big Challenge, The Tobacco Control Resource Centre, 2000. pgs. 4, 16, and 32.

Obtained online at:

http://www.tobaccocontrol.org/tcrc_Web_Site/Pages_tcrc/Resources/tcrc_Publications/Publications.htm

Nicotine Addiction in Britain, a report of the Tobacco Advisory Group of the Royal College of Physicians of London. Obtained online at: http://www.rcplondon.ac.uk/pubs/books/nicotine/